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Borough of Sewickley

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Building and Zoning Permit Application, Agreement, and Addendum

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1. Building and Zoning Permit Application This section is complete This section is incomplete
2. Building and Zoning Permit Agreement This section is complete This section is incomplete
3. Builiding and Zoning Permit Addendum This section is complete This section is incomplete

Building and Zoning Permit Application

Date
Applicant name
Phone
Applicant address
email
Property owner name
Phone
Property owner address
email
Location of property
Block/Lot #
Zoning district
Current/prior use of the building/land
Proposed use of the building/land
Is property in a Historic District?
1. Yes
2. No
Will there be any tree removal/pruning?
1. Yes
2. No
Description of the Construction
Estimated Cost
Architect/engineer
Phone
Address
Email
City
State
Zip Code
Builder
Phone
Address
Email
City
State
Zip Code
Workers Compensation Information
Insurer
Name of policy holder
Policy #
Federal tax ID #
Expiration date
**This applicant is responsible for obtaining required highway occupancy permits from the PA Department of Transportation
The above information is true and correct. I hereby agree that all applicable provisions of the borough codes will be complied with, as well as the requirements form the municipal water and sewage authority and the PA Department of Labor and Industry, whether specified or not.
Applicant Signature
Please enter your name.
Date
Date
Please enter today's date.
Printed name
*Original signature mandatory. Please print, sign, and submit to the Building Inspector.*
Continue

Building and Zoning Permit Agreement

Building and Zoning Permit Agreement
**This form must be signed by the owner of record and the applicant**
In consideration of the issuance by the Borough of Sewickley of a Building or Zoning Permit to the undersigned Applicant, the Applicant acknowledges that, in reviewing plans and specifications, in issuing permits, and in inspecting work of the Applicant, employees of the Borough are only performing their duties to require compliance with the minimum requirements of the applicable ordinances of the Borough pursuant to the police power of the Borough, and are not warranting to the Applicant or to any third party, the quality or adequacy of the design, engineering or work of the Applicant. The Applicant further acknowledges that it will not be possible for the Borough to review every aspect of the Applicant’s design and engineering, or to inspect every aspect of the Applicant’s work. Accordingly, neither the Borough nor any of its elected or appointed officials or employees shall have any liability to the applicant for defects or shortcomings should have been discovered during the Borough’s review or inspections.
The Applicant agrees to defend, hold harmless, and indemnify the Borough, its elected and appointed officials and employees form and against any and all claims, demands, actions, and causes of action of any one or more third parties arising out of or relating to the Borough’s review or inspection of the Applicant’s design, engineering or work, or issuance of a permit or permits, or arising out of or relating to the design, engineering or work done by the Applicant pursuant to such permit or permits. All references in this agreement are applicable to the Applicant’s employees, agents, independent contractors, subcontractors of any other persons or entities performing work pursuant to the issuance of the Building or Zoning Permit by the Borough.
Furthermore, the Applicant is hereby informed that any violation(s) of the Building Code and/or the Zoning Code for the Borough of Sewickley is subject to fines and penalties as stated in the applicable ordinance(s).
Applicant Signature
Please enter your name.
Date
Date
Please enter today's date.
Property Owner(s) Signature
Please enter your name.
Date
Date
Please enter today's date.
Property Owner(s) Signature
Please enter your name.
Date
Date
Please enter today's date.
(Must be notarized if the property owner is not the applicant)
Permit #
Date issued
Date issued
*Original signature mandatory. Please print, sign, and submit to the Building Inspector.*
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Builiding and Zoning Permit Addendum

Addendum to Building Permit
Submit Certificate of Workers' Compensation Insurance with Sewickley Borough as certificate holder or complete the Addendum to Building Permit Form below.
I. The applicant for the building permit, incompliance with Act 44 of 1993, hereby submits (check one):
1. Certificate of Insurance (please attach)
2. Certificate of Self-Insurance (please attach)
3. Affidavit of Exemption
II. If a certificate of Insurance of Self-Insurance has been submitted, please complete the following:
Name of Insurer or Self-Insurer
Address
City
State
Zip Code
Policy #
Coverage Period Ends
Name of Contractor/Policyholder
Address
City
State
Zip Code
Contractor/Policyholder’s Federal or State Employer Identification # (EIN)
1. This policy provides coverage for the requirements of the Workers’ Compensation Act, the Occupational Disease Act, and, where applicable, the Federal Longshore and Harbor Workers’ Compensation Act. 2. The insurer has been notified that the municipality issuing the building permit is to be named a policy certificate holder. 3. Any subcontractors used on this project will be required to carry their own workers’ compensation coverage. 4. The contractor/policyholder will notify the municipality of any change in status, cancellation, or expiration of workers’ compensation coverage. 5. Violation of the Workers’ Compensation Act or the terms of this permit will subject the contractor/policyholder to a stop-work order and other fines and penalties as provided by law.
III. If an exemption is being claimed, please complete the following and sign in the presence of a notary public: Basis for exemption (check one):
1. Applicant is an individual who owns the property
2. Contractor/Applicant is a sole proprietorship without employees
3. Contractor/Applicant is a corporation, and the only employees working on the project have and are qualified as “Executive Employees” under Section 104 of the Workers’ Compensation Act
4. All of the contractor/applicant’s employees on the project are exempt on religious grounds under Section 304.2 of the Workers’ Compensation Act.
5. Other.
Please Explain
If you have chosen one of the last three boxes, please explain.
Name of Applicant
Address
City
State
Zip Code
Applicant’s Federal or State Employer Identification # (EIN)
1. Any subcontractors used on this project will be required to carry their own workers’ compensation coverage.
2. The applicant is not permitted to employ any individual to perform work on this project pursuant to the permit in violation of the Act.
3. Violation of the Workers’ Compensation Act or the terms of this permit will subject the applicant to a stop-work order and other fines and penalties provided by law.
My signature on behalf of or as the contractor/applicant for this building permit constitutes my verification that the statements contained here are true, and that I am subject to the penalty of 18 Pa. C.S.A. S4909 relating to unsworn falsifications to authorities.
Signature
Please enter your name.
Name (Please print)
Title
Name of Company
*Original signature mandatory. Please print, sign, and submit to the Building Inspector.*
Pennsylvania League of Cities and Municipalities Note: Applicant’s copy to be attached to permit and posted. Municipality’s coy to be filed with its permit copy.